Personal Information

Do you hold a New York State license in this profession? *YesNo

Do you have a Social Security Number? *YesNo

Date of Birth *

Country *

First Name *

Middle Name

Last Name *

Address Line 1 *

Address Line 2

City *

Phone Number *

E-Mail Address *

Address Type *BusinessPersonal

Accommodations

I have been diagnosed as having a disability and require reasonable accommodations and am submitting the Request for Reasonable Testing Accommodations form. I understand that I will not be able to test until I submit the appropriate documentation and am approved to test with accommodations. *YesNo

History

Do you have another name that appears on a degree or other credentials? *YesNo

Have you ever applied for New York State licensure in any profession? *YesNo

Moral Character

Have you ever been found guilty after trial, or pleaded guilty, no contest, or nolo contendere to a crime (felony or misdemeanor) in any court? *YesNo

Are criminal charges pending against you in any court? *YesNo

Has any licensing or disciplinary authority refused to issue you a license or ever revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, refused to renew a professional license or certificate held by you now or previously, or ever fined, censured, reprimanded or otherwise disciplined you? *YesNo

Are charges pending against you in any jurisdiction for any sort of professional misconduct? *YesNo

Has any hospital, licensed facility, or clinical laboratory restricted or terminated your professional training, employment, or privileges or have you ever voluntarily or involuntarily resigned or withdrawn from such association to avoid imposition of such measures? *YesNo

Previous Nursing Licenses

If you have ever taken the SBPT, NCLEX, or a state-constructed examination for licensure as either a Registered Professional Nurse or a Licensed Practical Nurse in the United States or its territories (except New York State), please mark "Yes" below. Otherwise, please select "No". *YesNo

Do you hold an RN license in another state or U.S territory? *YesNo

Education

Elementary or Primary School

Name of School/Issuer *

City *

State/Province *

Country *

Number of years attended *

Start Date *

End Date *

High School/Secondary School/Equivalency Diploma Issuer

Name of School/Issuer *

City *

State/Province *

Country *

Number of years attended *

Start Date *

End Date *

Did you graduate? *YesNo

Type of Diploma or Certificate awarded? *

Date Diploma or Certificate awarded? *

Nursing Program

Name of School/Issuer *

City *

State/Province *

Country *

Number of years attended

Have you received this degree/diploma/certificate? *YesNo

Start Date *

End Date *

Major/Concentration

Title of Degree/Diploma/Certificate awarded (in the original language)

Educated Outside of the United States *YesNo

Education Document - Upload

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Do you now hold, or have you ever held, a license or certificate to practice any profession in any state or jurisdiction? *YesNo

Child Support Obligation  

Everyone applying for a professional license, permit, or registration, or any renewal thereof, must certify that, as of the date of the filing, she or he is, or is not, under an obligation to pay child support under section 3-503 of New York State General Obligations Law. Individuals who are four months or more in arrears in child support or who have failed to comply with a summons, subpoena or warrant relating to a paternity or child support proceeding may be subject to suspension of their business, professional, drivers and/or recreational licenses and permits. The intentional submission of false written statements for the purpose of frustrating or defeating the lawful enforcement of support obligations is punishable under section 175.35 of the Penal Law.

You must complete this section before we can issue the credential for which you have applied. Individuals who are not in compliance with their obligation to pay child support can be issued a credential for no more than six months in order to comply with their child support obligations.

Are you under any obligation to pay child support? *I am not under an obligation to pay child supportI am under an obligation to pay child support

Citizenship/Immigration Status

Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of professional licenses, registrations and limited permits to United States citizens or qualified aliens. To comply with Federal law and Commissioner's regulation, you must complete this section of this form and check the appropriate box below which indicates your citizenship/immigration status. *A United States citizen or National.An alien lawfully admitted for permanent residence in the United States.An alien granted asylum under Section 208 of the Immigration and Nationality Act.A refugee granted asylum under Section 207 of the Immigration and Nationality Act.An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1 year.An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April 1980.Non-Immigrant (Temporarily in U.S.).An alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or similar relief from deportation.I do not reside in the United States.

Passport/Immigration Document - UploadUpload 1 supported file. Max 100 MB.

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Coursework

For more information on this requirement, including a listing of approved providers, refer to Mandated Training Related to Child Abuse.

Child Abuse Identification and Reporting Coursework Requirement *I graduated from a NYS registered program and completed the child abuse identification training as part of my studies.I completed the child abuse coursework and will attach a certificate of completion from an approved provider.I completed the child abuse coursework and will mail a copy of the certification of completion to the Office of the Professions.I completed the child abuse coursework online and the approved provider will report that to you electronically.I am filing for an exemption to the requirement. (You will need to use the Form 1CE Certification of Exemption).

Child Abuse Training Document - Upload *Upload 1 supported file. Max 100 MB.

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Training Requirements

For more information on this requirement, including a listing of approved providers, refer to Mandated Training Related to Infection Control.

Infection Control Training Requirement *I graduated from a NYS registered licensure qualifying program within the last four years and completed the infection control training as part of my studies.I completed the infection control training within the last four years and will attach a certificate of completion from an approved provider.I completed the infection control training within the last four years and will mail a copy of the certificate of completion to the Office of the Professions.I completed the infection control training online within the last four years and the approved provider will report that to you electronically.I am filing for an exemption to the requirement (You will need to use the Form 1IC Attestation of Infection Control Training).

Infection Control Training Document - UploadUpload 1 supported file. Max 100 MB.

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Gender and Ethnicity

Information on gender and ethnicity is sought solely to allow the New York State Education Department to collect and analyze data concerning diversity in the licensed professions. The ethnic and gender data you provide will be used only for statistical, research, and program evaluation purposes. It will not be released to the public. This information has absolutely no bearing on your qualification for licensure.

What is your gender? *MaleFemaleOther

What is your ethnicity? *AsianBlack (not Hispanic)HispanicNative AmericanPacific IslanderWhite (not Hispanic)Other

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